Friday Feedback: When Drug Price Is a Factor

We reached out to a diverse group of specialists to get their take on how they discuss extremely expensive drugs with patients.

This week, Friday Feedback takes a second look at extremely pricey therapeutics, as in the case of the anti-HCV drug sofosbuvir (Sovaldi) that promises a "cure" for $1,000 a pill. Then there's ivacaftor (Kalydeco) for cystic fibrosis that costs $300,000 a year. And it's an issue that crosses many specialties.

We reached out to a diverse group of specialists by email and asked them to respond to the following questions:

How do you advise patients about expensive drugs that you believe would provide the best therapy? Have you come upon any strategies that you feel are particularly effective in discussing this problem?

The participants this week:

Eugenia Gianos, MD, cardiologist, director of the inpatient preventive cardiology consult service and assistant professor, Leon H. Charney Division of Cardiology at NYU Langone Medical Center in New York City

Jerry Nick, MD: "We always have to do the financial piece before assuming a patient is going to get something. If it isn't going to work we try to find something else, but we have very few low-cost options. Sometimes admitting a patient to the hospital is cheaper than trying to treat as an outpatient."

S. Yousuf Zafar, MD, MHS: "Yes, discussing costs in the clinic room can be uncomfortable, but our studies have shown that patients suffer both in their well-being and in the quality of care due to costs. Broaching the topic of costs might save a lot more than money down the road. As a part of my practice as a medical oncologist, I am careful to educate patients about these potential out-of-pocket costs before sending them off with a prescription."

Eugenia Gianos, MD: "In the case of heart failure treatment, there are now many advancements in end-stage disease that are improving quality of life and longevity, but physicians should feel a sense of responsibility in determining whether a very expensive medication or treatment is warranted based on prognosis and the amount of benefit that would be derived. Without that sense of responsibility on the part of healthcare providers, our healthcare system is not likely to be able to sustain itself."

Uzma Haque, MD: "We usually resort to expensive treatments in rheumatoid arthritis [RA] when the patient has tried and failed first-line therapy. I inform the patient that treatment is expensive but usually well-covered by insurance companies (at least in RA) and that the cost over a lifetime is an important consideration but is usually offset by individual productivity towards the society."

Marilynn Prince-Fiocco, MD: "It becomes the obligation of the physician, in conjunction with the pharmaceutical company and the patient -- and the FDA -- to understand the science and the statistics behind any new drug offering."

Necessary Burden

Nick: "Most of our 'expensive' drugs are so expensive ($5,000 a month to $25,000 a month) that they come with special patient assistance programs. Even for our most wealthy patients, paying out of pocket for medications isn't an option."

Gianos: "In cardiology, there are now numerous drugs that have been effectively used for many years and are now generic and cost-effective for patients. In some circumstances, a newer, more expensive medication may be required because of improved platelet inhibition, cholesterol-lowering or a unique anti-inflammatory benefit."

Zafar: "Cancer care is among the most expensive in the U.S. Much of this expense comes from the rising cost of cancer drugs, which in some instances can cost tens of thousands of dollars a month. Further, many new cancer drugs are being developed in the form of pills. As a result, when patients take prescriptions for pill chemotherapy to their pharmacy, they are often faced with prescription copayments of hundreds of dollars a month."

Prince-Fiocco: "These patients never have the resources to buy the drug -- it does become a cost borne by insurance or the pharmaceutical company on a compassionate need basis -- and, hence, society. However, it may be the prototype of a yet more expensive regimen that would serve more patients, and then the cost becomes more problematic."

Cost-Benefit Calculation

Gianos: "With every drug, procedure, and treatment, there needs to be an individual cost-benefit analysis. In the case of a drug that provides a cure, like the new drug sofosbuvir for HCV, the cost of $1,000 per pill is likely cost-effective in the long-term considering the alternative of treatment of the disease over many years and the potential for development of hepatocellular carcinoma. In this case, the medication is both cost-effective for the patient and the healthcare system."

Prince-Fiocco: "The concept of marginal benefit of a new addition to a sometimes staggering list of other drugs (and here, cardiology meds pose a serious problem) may be similar to the cost of a single new medication for a more limited population."

Talking to Patients

Nick: "We have two social workers in clinic that go through the patient assistance programs and the various insurances and figure out if we can get these drugs. I just tell the patients they are going to have to work with the social worker to figure out how to get the drugs. Then the social worker tells me if it is going to happen or not. Everything requires a prior authorization, which is a long time on the phone for our clinic staff."

Haque: "I have no particular strategy ... except for being honest and open towards patients concerns and opinions. And please remember that unlike other medications, rheumatoid arthritis biologics are usually in the $30,000 to $40,000 range per year. But certainly over several years, this can add up."

Gianos: "For each patient, individual risk needs to be assessed to determine whether the patient would really derive benefit from the more expensive agent in an effort to contain cost and improve patient adherence as well as to reduce the costs to our healthcare system."

Prince-Fiocco: "Ivacaftor is designed for a very specific, limited population -- in this case, the cystic fibrosis patients who harbor the mutation where benefit has been shown. For that small group, it is my pleasure to discuss the possibility of a potentially significant benefit for a life-limiting (terminal) disease."

Zafar: "To start, I will often ask patients if they have prescription drug coverage. Additionally, I will ask our clinic pharmacist to review the patient's insurance information so the patient has an estimate of their treatment-related out-of-pocket costs. While drug costs are expensive, it's important for providers to consider indirect costs associated with cancer care. For example, patients often take time off and pay for travel to our cancer center. These costs add up over the course of treatment that can sometimes span years."

Friday Feedback is a feature that presents a sampling of opinions solicited by MedPage Today in response to a healthcare issue, clinical controversy, or new finding reported that week. We always welcome new, thoughtful voices. If you'd like to participate in a Friday Feedback issue, reach out to e.chu@medpagetoday.com or @elbertchu.

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